…a shared responsibility for health care

How Medication Reconciliation Supports

Patient Safety15 September 2007

Jane Richardson, BSP, PhD, FCSHPCoordinator, Clinical Pharmacy ServicesTeam Lead, SCH Med Rec Pilot Site

Objectives

• To define Medication Reconciliation & describe why it’s important.

• To outline our initial experience with admission Medication Reconciliation within the Saskatoon Health Region (SHR).

• To describe early use of the Pharmaceutical Information Program (PIP) auto-populated Medication Reconciliation form in SHR Emergency Departments.

Medication Reconciliation – what is it?• A formal process of:

– Obtaining a complete and accurate list of each patient’s current home medications (name, dosage, frequency, route)

– Comparing the physician’s admission, transfer, and/or discharge orders to that list

– Bringing discrepancies to the attention of the prescriber and ensuring changes are made to the orders, when appropriate

Reference: IHI, Getting Started Kit: Prevent Adverse Drug Events (Medication

Reconciliation)

Institute for Healthcare Improvement• The Institute for Healthcare Improvement introduced the 100K

Lives campaign, December 2004, to challenge health care providers to join a national effort to make health care safer & more effective & ensure hospitals achieve the best possible outcomes for all patients

– How? Implement six targeted strategies proven to prevent

adverse events

• The initiative captured the attention of Canadian care providers, hospital administrators & others committed to improving patient safety.

• On April 12, 2005, the Canadian campaign, Safer Healthcare Now! was created.

IHI / Safer Healthcare Now! Initiatives• Improved care for AMI• Prevent surgical site infections• Prevent central line infections• Prevent ventilator associated

pneumonia• Deploy rapid response teams• Prevent adverse drug events:

Medication reconciliation

Why Medication Reconciliation?

• 2.9-16.6% of patients, in acute care hospitals, have experienced one or more adverse events

• Adverse drug events are a leading cause of injury to hospitalized patients

• Greater than 50% of all hospital medication errors occur at the interfaces of care – Admission to hospital– Transfer from one nursing unit to another– Transfer to step-down care– Discharge from hospital

Why Medication Reconciliation?

• Frequency of medication discrepancies on a general medicine clinical teaching unit

– 53.6% of patients had at least one unintended discrepancy

– 38.6% of the discrepancies were judged to have the potential to cause moderate – severe discomfort or clinical deterioration

– Most common error was an omission of a regularly used medication (46.4%)

Arch Intern Med, 2005

SCH Patient: MP• 76 y.o. woman attending GDH admitted to CCU with

bradycardia, then returned to GDH after receiving a pacemaker

• CCU admission medication orders based on faxed hand-written list from community pharmacy

• Errors:– Lescol 20mg written as Losec 20mg (Rx error)– Tramacet recorded as Tagamet (MD error)– On warfarin for AF: not ordered on admission or restarted

on discharge– Sertraline & metformin put on hold in hospital but not

reordered on discharge• Community pharmacist had no idea what this woman

should or shouldn’t have in her blister pack

Medication Reconciliation – the solution?

• Medication Reconciliation can:1. Prevent omission of an at-home

medication2. Match in-house dose, frequency, and

route with at-home usage3. Ensure medications follow the patient

from one care site to another

Why Now? • It’s the right thing to do……..

– Culture of safety: reduce medication errors & potential for patient harm

– Key component of seamless care strategies– Saves time for physicians, nurses, and pharmacists in

the long-term

• Medication Reconciliation is a Canadian Council on Health Services Accreditation Standard (ROP)

• In the SHR, Senior Leadership has endorsed Medication Reconciliation as a Regional Project of high priority

SHR Form and Process

• A formal process of:– Obtaining ONE complete and accurate list of each

patient’s current home medications (name, dosage, frequency, route)

– Using the information obtained to write the admission orders

– Referring back to the information obtained to write transfer and discharge orders

SHR ManualMedication Reconciliation

Form and Process

Medication ReconciliationForm, page 2

Measuring Progress: Discrepancies

• Undocumented intentional discrepancy:– physician made an intentional choice to add,

change or discontinue a medication but this choice is not clearly documented

• Unintentional discrepancy:– physician unintentionally changed, added or

omitted a medication the patient was taking prior to admission

• Goal: – reduce number of discrepancies by 75%

SHR Baseline Data (5 Pilot Sites)

• Undocumented Intentional Discrepancies:– 1.32 / patient

– Goal: 0.33 / patient

• Unintentional Discrepancies:– 1.28 / patient

– Goal: 0.32 / patient

1.0 Mean Number of Undocumented Intentional Discrepancies

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

Nov 200

5

Jan

2006

Mar

2006

May

2006

Jul 2

006

Sep 2

006

Nov 200

6

Jan

2007

Mar

2007

May

2007

Jul 2

007

Sep 2

007

Nov 200

7

Jan

2008

Mar

2008

May

2008

Month

Mea

n

Actual Goal

Are we making a difference?

Baseline

PDSA 1survey

PDSA 2

Edu

catio

n

PDSA 3

PDSA 4

Reviseform

1 yr datacheck

National: 1.1

National: 0.6

2.0 Mean Number of Unintentional Discrepancies

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

Nov 2

005

Dec 2

005

Jan

2006

Feb 2

006

Mar

200

6

Apr 2

006

May

2006

Jun

2006

Jul 2

006

Aug 2

006

Sep 2

006

Oct 20

06

Nov 2

006

Dec 2

006

Jan

2007

Feb 2

007

Mar

200

7

Apr 2

007

May

2007

Jun

2007

Jul 2

007

Aug 2

007

Sep 2

007

Oct 20

07

Nov 2

007

Dec 2

007

Jan

2008

Feb 2

008

Mar

200

8

Apr 2

008

May

2008

Jun

2008

Month

Me

an

Actual Goal

Are we making a difference?

Baseline

PDSA 1survey

PDSA 2

Education

PDSA 3

PDSA 4

Reviseform

1 yr datacheck

National: 1.2

National: 0.65

Comments on the Manual Form

• It’s a blank form!– All medication information will have to be written in:

• Will need to get the information from someone or somewhere.

• How accurate is that information?• Potential for transcription errors when recording the

medication history.

• We need to get the medication history right for the rest of the process to work

The Next Step

Using PIP to Generate

an Admission

Medication Reconciliation Form

PIP Auto-populatedMedication

ReconciliationForm

Has it made a difference?

• SCH Emergency Admissions to General Medicine:– Undocumented Intentional Discrepancies

• SHR Goal: 0.33 / patient• April 2007 (Manual Form): 0.1• September 2007 (PIP Form): 0.2

– Unintentional Discrepancies• SHR Goal: 0.32 / patient• April 2007 (Manual Form): 3.1• September 2007 (PIP Form): 1.3

Comments on the PIP Auto-populated Form• Gives medication name, strength, most recent

fill date & prescriber’s name– A better starting point than a blank page, especially

if a patient or caregiver cannot provide information.• Dose & interval still need to be clarified (& may be

different than what was on the original prescription)• Still need to ask about medications not recorded on

PIP

– Avoids name & strength transcription errors for auto-populated medications

Conclusions

• Medication Reconciliation does decrease medication errors

• The Pharmaceutical Information Program auto-populated history and admission order form is a valuable tool for this initiative

• Through collaboration we are advancing patient safety in Saskatchewan